Objective: Abatacept is a selective T-cell co-stimulation modulator and is an effective new therapy for rheumatoid arthritis. This study evaluated the efficacy and safety of abatacept in patients with rheumatoid arthritis.
Methods: A total of 38 patients (17 naïve, 21 switching) began abatacept treatment with a dose of 500 or 750 mg according to body weight.
Results: At 24 weeks, the following response rates were observed for all patients, naive patients, and switching patients, respectively: good European League Against Rheumatism responses of 39.5%, 41.2%, and 38.1% were attained; remission rates in terms of DAS28 (erythrocyte sedimentation rate) were 26.3%, 41.2%, and 14.3%; and simplified disease activity index scores were 18.4%, 35.3%, and 4.8%. Mean changes in matrix metalloproteinase-3 (MMP-3) concentration were greater for good responders versus nonresponders (−121 versus −42.8 ng/ml). The incidence of serious infections was 2.6% (pneumonia).
Conclusion: In this study, abatacept significantly reduced disease activity in patients with rheumatoid arthritis. The measure of effectiveness was the change in MMP-3 concentration. Switching patients seemed to make better progress than naive patients did. Abatacept demonstrated clinically meaningful efficacy and acceptable safety.

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Introduction: Recently, we reported that PAMPS and PDMAAm gels induce the chondrogenic differentiation of ATDC5 cells in vitro in maintenance medium without insulin. We hypothesized that hyaluronic acid (HA) affects the in vitro induction effects of PAMPS and PDMAAm gels on the chondrogenic differentiation of ATDC5 cells, depending on the concentration. The purpose of this study was to test this hypothesis.
Methods: This study consisted of three sub-studies: the first was performed to assess the fundamental effects (without HA) of the PAMPS gel, PDMAAm gel, and polystyrene dish surfaces on the chondrogenic differentiation of ATDC5 cells cultured in maintenance medium and in differentiation medium (containing insulin). The second and third sub-studies were performed to analyze the effects of HA supplementation (three concentrations) of the two media on the chondrogenic differentiation of ATDC5 cells cultured on PAMPS and PDMAAm gels, respectively. At 7 days of culture, the gene expression of cartilage markers was examined using real-time polymerase chain reaction analysis.
Results: On the PAMPS gel with the maintenance medium, HA at concentrations of 0.01 and 0.10 mg/mL significantly increased the expression of Col-2 mRNA and aggrecan mRNA in comparison to those without HA. In the cells cultured in the differentiation medium, HA at a concentration of 0.01 mg/mL significantly increased mRNA expression of Col-2 and aggrecan genes in comparison to those without HA. On the PDMAAm gel with the maintenance medium, HA at a concentration of 1.00 mg/mL significantly reduced the expression of these genes in comparison to those without HA.
Conclusion: Mechanical signals from each hydrogel surface significantly affect the chondrogenic differentiation of ATDC5 cells, and HA affects the mechanical signals from each hydrogel surface, depending on the concentration.

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Objective: The aims of the present study were first to investigate the frequency and location of bone cysts in the acetabulum of hip osteoarthritis (OA) patients and second to examine the influence of pelvic tilt on the location of bone cysts in the acetabulum.
Methods: A total of 80 patients (65 women and 15 men) with hip OA who underwent primary total hip arthroplasty were included in this study. The mean age at surgery was 65 years (range, 43-83 years). The bilateral hips of these 80 patients were examined; however, 9 contralateral hips that had previously been implanted with prostheses were excluded. We evaluated the minimal joint space width (MJS) on preoperative antero-posterior radiographs of the pelvis in the standing position. We also obtained the digital imaging and communication in medicine (DICOM) data from the preoperative pelvic computed tomography (CT) images, and then three-dimensionally reconstructed the DICOM data using OrthoMap 3D software with reference to the anterior pelvic plane. We divided the acetabulum into six areas and examined the presence of bone cysts in each area. We also examined the degree of pelvic tilt with three-dimensionally reconstructed CT images.
Results: The frequency of bone cysts on CT images increased when the MJS of the hip joint on radiographs of the pelvis was less than 2 mm (p < 0.05). In the total of 151 hips, the antero-lateral area of the acetabulum (88 hips, 58%) exhibited the highest frequency of bone cysts. Patients who had bone cysts in the anterior part of the acetabulum tended to have a larger value of pelvic retroversion than those who did not have cysts in the anterior part of the acetabulum; however, the difference was not significant.
Conclusion: The antero-lateral area of the acetabulum, which exhibited the highest frequency of bone cysts, is thought to be susceptible to loading stress. We hypothesized that patients who have bone cysts in the anterior part of the acetabulum have larger retroversion of the pelvis than others; however, the difference was not significant. We need to investigate further to reveal the influence of pelvic tilt on the location of bone cysts.

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Objective: Soft-tissue balancing of the knee is fundamental to the success of total knee arthroplasty (TKA). The most important clinical goal in TKA is the preparation of equal and rectangular extension and flexion joint gaps because this facilitates the functional restoration of the knee. However, particular attention should be paid to the design of the articulating surface of the total knee prosthesis because it may adversely influence the joint gap. It has always been difficult to accurately assess the intra-operative joint gap during trial reduction of the components. The purpose of this study was to compare the intra-operative joint gap of two posterior-stabilized (PS) prostheses having different shapes of articulating surface (namely, fixed-bearing PS prostheses and mobile-bearing PS prostheses) with the use of a unique tensor device.
Methods: We measured the intra-operative joint gap in 65 knees in patients undergoing PS TKA. First, the femoral and patellar trial components of a fixed-bearing prosthesis were inserted. The joint gap was measured using a tensor device having the same shape as the fixed-bearing polyethylene insert (FB-PS gap). The center width and asymmetry (tilting) under 120 N of distracting force were measured at 0°, 30°, 45°, 60°, 90°, 120° and maximum flexion of the knee with the patellofemoral joint reduced and the quadriceps tendon sutured. Second, the femoral and patellar trial components were changed to mobile-bearing prostheses having the same chamber shape but different articulating surfaces. The joint gap was also measured using a tensor device having the same shape as the mobile-bearing polyethylene insert (MB-PS gap).
Results: From 30° to 120° flexion of the knee, the MB-PS gap tended to be smaller than the FB-PS gap. At 30°, 45°, and 60° flexion, the MB-PS gap was significantly smaller than the FB-PS gap.
Conclusion: This study showed that the joint gap was largest at 30° flexion of the knee in both PS prostheses. This may result in mid-flexion instability of PS prostheses. However, the joint gap at 30°, 45°, and 60° flexion of the MB-PS prosthesis was significantly less than that of the FB-PS prosthesis. These results suggest that the design of the total knee prosthesis affects the intra-operative joint gap and could reduce mid-flexion instability.

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Objective: The aim of this study was to evaluate the efficacy of operative treatment for osteochondritis dissecans (OCD) of the knee based on the International Cartilage Repair Society (ICRS) classification.
Methods: This study included 24 patients with OCD of the knee (19 males, 5 females; mean age, 16 years). Patients were treated according to the ICRS classification. Patients classified as grade I-IV were treated as follows: grade I/II - arthroscopic retroarticular drilling (9 cases), grade III - in situ fixation by autologous osteochondral graft (AOG, 4 cases), and grade IV - autologous chondrocyte implantation (9 cases), AOG (1 case), or osteosynthesis with poly-L-lactic acid pins or bone pegs (2 cases). The healing time and bone union rate were evaluated by X-ray photographs and clinical results were examined by Lysholm score pre- and postoperatively for each grade.
Results: Bone union was achieved except in one grade II patient. The mean healing time was 4.5 months in the grade I/II and 6.5 months in the grade III patients. Pre-and postoperative Lysholm scores were 70±8.6 and 97±4.7 points in grade I/II patients, 71±12 and 97±2.8 points in grade III patients, 72±8.2 and 95±6.0 points in grade IV patients, respectively.
Conclusion: Operative treatments based on ICRS classification were effective for treating OCD of the knee.

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Objective: There are many surgical techniques applicable to rheumatoid forefoot deformities. The purpose of this study was to determine the results of arthrodesis of the first metatarsophalangeal (MTP) joint with resection arthroplasty of the metatarsal head of the second through fifth toes.
Methods: Seven feet in 13 patients with a minimum of 3 years postoperative follow-up were evaluated. Clinical examination, radiological measurements, and the occurrence of complications were used to evaluate the results. Forefoot pain, footwear status, walking performance, plantar callus, and patient satisfaction were examined and classified into four grades. The hallux-valgus angle, M1M2 angle, and M1M5 angle were measured preoperatively, 3 weeks postoperatively, and at final follow-up. Complications included screw cutout, toe necrosis, and superficial infection.
Results: On clinical evaluation, forefoot pain, walking performance, and patient satisfaction were rated as excellent or good in most cases. Radiographic measurement of the hallux-valgus angle and M1M2 angle showed significant improvement 3 weeks postoperatively and also at the last follow-up compared with the preoperative value. In contrast, the M1M5 angle was significantly different between pre-operative and final follow-up measurements only.
Conclusion: The outcome of this operation suggests the effectiveness of arthrodesis of the MTP joint of the great toe and resection arthroplasty of the metatarsal head of the lesser toes for rheumatoid forefoot deformities.

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This report presents a case in which preoperative simulation was performed using three-dimensional computed tomography (CT) reconstruction images and stereolithographic models before bilateral reimplantation for damage accompanied by a massive bone defect associated with a total elbow arthroplasty (TEA) implant. A 64-year-old man with rheumatoid arthritis (who had undergone left TEA using a Souter-Strathclyde implant 18 years earlier) experienced implant failure and dislocation of the implant. There were large bone defects of the humerus and the ulna, which could have resulted in insufficient fixation during reimplantation. However, preoperative simulation using three-dimensional CT reconstruction images and stereolithographic models showed that sufficient fixation could be achieved. Surgery was successfully performed according to the preoperative plan. This patient had previously undergone right TEA, and this implant had been removed 14 years earlier without reimplantation. A similar preoperative simulation on the right elbow demonstrated that the procedure could be performed, despite a large bone defect of the humerus. This method made it possible to perform a detailed investigation to determine the appropriate implant size and the correct site of entry. Such simulations could be applied in the field of orthopedic surgery using material models.

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Muscle contractures as a complication of intramuscular (IM) injections in childhood are widely known; however, since the number of cases is decreasing, recognition of the syndrome is not as high now as it was in the past. We report three patients with contractions of the gluteal muscle who presented with advanced snapping hip syndrome and functional impairment. Three female patients (6 legs) were referred to our clinic with snapping hips and walking disturbances that developed in later childhood; all received IM injections in the gluteal area in earlier childhood. At presentation, all 6 legs were externally subluxated and gait disturbance developed due to abductional contractures and markedly limited leg adduction. One patient underwent surgery on one leg (conservative management was chosen for the other leg) and two patients underwent operations on both legs. The necessary range of fascia and tendon was excised in all cases. Functional improvement was obtained in all cases immediately after the operation. An average of 32 months postoperatively, the outcomes are good and the clinical courses uneventful. The causes of muscle contraction in the gluteal area include injuries, radiotherapy, and IM injections. In severe cases, contractions may lead to functional impairments of the hip joint and cause gait disturbances and snapping hip syndrome, as in the reported cases. The severity of illness is often related to the grade of contractures. Detailed understanding of anatomical and mechanical relationships in the contracted region is required for an operation to be successful. After sufficient excision of the fascia and tendon(s), a favorable postoperative course usually can be obtained.

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There are few reports showing the results of minimally invasive total hip arthroplasty (MIS-THA) for osteoarthritis in patients with Parkinsonism. Here, we report two cases of osteoarthritis treated by MIS-THA using the anterolateral-supine approach (ALSA) in patients with Parkinsonism. The first case involved a 75-year-old woman with Parkinson syndrome who presented to our hospital with severe right hip joint pain in 2010. The patient had osteoarthritis of the hip and underwent MIS-THA utilizing ALSA in January, 2011. The surgical time was 88 min and the estimated blood loss during surgery was 495 ml. At present, 8 months postoperatively, the patient is pain free and is able to walk with a walking frame. The second case involved a 71-year-old woman with Parkinson disease who also presented to our hospital with severe right hip joint pain in 2010. The patient had osteoarthritis of the hip and underwent MIS-THA utilizing ALSA in February, 2011. The surgical time was 100 min and the estimated blood loss during surgery was 314 ml. At present, 8 months postoperatively, she is also pain free and is able to walk with a walking frame. One of the complications we should try to prevent following THA for osteoarthritis in patients with Parkinsonism is postoperative dislocation. Therefore we performed MIS-THA utilizing ALSA in these two cases, leading to good postoperative functional outcomes. It is our belief that muscle-preserving MIS-THA using ALSA is a promising strategy for osteoarthritic hips in patients with Parkinsonism.

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Rupture of the peroneus longus tendon is rare. We report the case of a 23-year-old man who played rugby in the top Japanese league. He found it difficult to continue playing rugby because of pain over the lateral aspect of both feet. Tenderness and swelling were localized in the lateral calcaneal region. X-ray images showed a bony eminence lateral to the calcaneus in both feet. After conservative treatment, surgery was performed. In the right foot, the peroneus brevis was found to be intact and the peroneus longus was ruptured. A bony eminence was resected and the ruptured tendon was sutured. In the left foot, there was degeneration of the peroneus brevis, and the peroneus longus was ruptured. A bony eminence was resected and the ruptured tendon was fixed to the calcaneus with anchoring suture. Repetitive friction between tendon and bony eminence had caused rupture of the peroneus longus tendon in both feet. The patient was able to resume playing rugby 4 months after surgery.

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